Healthcare Provider Details

I. General information

NPI: 1982985933
Provider Name (Legal Business Name): JOHN IBIAM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2011
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 SOUTH AVE STE 404
STATEN ISLAND NY
10314-3411
US

IV. Provider business mailing address

10902 169TH PL
JAMAICA NY
11433-2932
US

V. Phone/Fax

Practice location:
  • Phone: 800-277-4680
  • Fax: 888-556-9797
Mailing address:
  • Phone: 718-570-1692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103937
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: